PickingandPulling101

Picking and Pulling 101
(BFRBs: An Overview)
TLC National Conference
April 23, 2010
Fred Penzel, Ph.D.
Western Suffolk Psychological Services
Huntington, New York
All human beings (and most other
mammals) pull, pick, and bite at
themselves to one degree or
another. It is therefore really a
matter of degree when we begin to
call these behaviors „disorders.‟
What are the disorders that
involve picking and pulling?
TRICHOTILLOMANIA (312.39)
DSM-IV CRITERIA
• Recurrent pulling out of hair resulting in
noticeable loss
• Increasing sense of tension before or when
attempting to resist
• Pleasure, gratification or relief when pulling out
the hair
• Disturbance not accounted for by any other
disorder
• The disturbance causes significant distress or
impairment in social, occupational or other
important areas of functioning
IMPULSE-CONTROL DISORDER
NOT OTHERWISE SPECIFIED
(312.20) DSM-IV CRITERIA
This category is for disorders of
impulse control that do not meet the
criteria for any specific Impulse-Control
Disorder or for another mental disorder
having features involving impulse
control described elsewhere in the
manual ( e.g., Substance Dependence,
a Paraphilia).
François Henri
Hallopeau
(1842-1919)
A French
dermatologist who
first used the term
Trichotillomania in
1889 to describe a
patient who had
pulled out his hair.
Louis Bracq
(1856 – 1928)
A French dermatologist
who coined the term
“Acne Excoriee” in
1907.
IMPULSE CONTROL DISORDERS
• Intermittent Explosive Disorder
• Kleptomania
• Pathological Gambling
• Pyromania
• Trichotillomania
• Impulse Control Disorder Not Otherwise
Specified (NOS)
Body Focused Repetitive Behaviors
(BFRBs)
• Trichotillomania (compulsive hair pulling)
• Onychophagia (compulsive nail biting)
• Dermatotillomania (compulsive skin
picking)
• Compulsive nose picking
• Compulsive biting of the inside of the
cheek
• Lip biting or picking
How Common are BFRBs?
• Trichotillomania (Christensen and Mackenzie, 1994)
1.5 % males – nonclinical college sample
3.6 % females – nonclinical college sample
• Skin Picking (Bohne et al, 2002)
4.6 % of a nonclinical college sample
• Nail Biting (Teng et al, 2002)
6.4 % of a nonclinical college sample
• Mouth, lip, or cheek chewing (Teng et al, 2002)
5.7 % of a nonclinical college sample
What Is The Sex Ratio In TTM?
Christenson et al (1994)
65% of those with TTM found to be female
Stemberger et al (2003)
90% of adult TTM sufferers in study reported to be female
Kress et al (2004)
Males may be statistically underrepresented as they have a
wider variety of areas to pull from, and may
be better able to conceal their pulling. They may also be
able to blame their pulling on male pattern baldness.
What do people with these
disorders actually do?
Three Major Types Of BFRBs
• Automatic – done with little awareness during
some other activity. May be more tic-like.
May account for up to 75% of hair pulling.
• Deliberate or focused – starts with an urge
and is done in place of any other activity.
May be more compulsive with perfectionistic
and ritualistic features.
• A combination of both - done at various times
and in different situations.
Types of Stimulation Sought After in
Body-focused Repetitive Behaviors
• Tactile
• Visual
• Oral
Pulling Sites In TTM
Location % Endorsing
Scalp 79
Eyebrows 65
Eyelashes 59
Pubic Area 59
Legs 30
Arms 17
Other 25
(N = 1,697) (TIP unpublished data, 2006)
PRIMARY SKIN PICKING SITES
Location Percentage
Pimples and scabs 87
Red, swollen, or infected spots 58
Healthy skin 52
Mosquito bites 48
Scars 42
(N = 31) (Wilhelm et al, 1999)
Post-pulling Behaviors Seen In TTM
• Stroking the hair against the mouth, face, or tongue
• Staring at/studying the hair, or parts of the hair (e.g.
root, looking for a drop of blood, etc.)
• Rolling it in a ball
• Tying it in a knot
• Playing with the hair
• Winding it around a finger
• Saving it in a special spot or container
• Performing a ritual or ceremony with it
• Biting or chewing the hair, or pulling it between the
teeth
• Breaking the hair or pulling off the bulb at the end
• Biting off and/or chewing the bulb at the end of the hair
• Swallowing the hair
What Impact Do BFRBs Have
On People‟s Lives?
THE EMOTIONAL EXPERIENCE OF
BFRBs
• Depression
• Shame
• Secrecy
• Isolation
• Loneliness
• Feelings of unattractiveness
and defectiveness
Strategies Used by BFRB Sufferers to
Conceal Their Problems
• wigs • comb hair over bare
spots
• kerchiefs • spray-on hair
• hats • not going out
• false eyelashes publicly
• eyebrow pencil • cover makeup
• band-aids
• cut other hairs short • avoiding bright light
• shave entire head • hands in pockets
• hairpiece • covering with
clothing
Emotional Responses to TTM
Percent
Low self-esteem 84
Diminished sense of attractiveness 82
Shame and embarrassment 80
Problems with tension or anxiety 68
Depression or mood problems 66
(Mansueto et al, 1990)
Activities Avoided by TTM Sufferers
Percent
Haircuts 87
Swimming 62
Being outside in the wind 42
Sports 35
Sexual Intimacy 35
Lighted areas 25
Public activities 22
(Stemberger et al, 2000)
Problems Seen To Co-occur With TTM
(Christenson et al, 1995)
(N = 186) Percent
• Major Depression 51.6
• Generalized Anxiety Disorder 27.0
• Alcohol Abuse 19.4
• Other substance abuse 16.1
• OCD 13.4
• Social Phobia 11.3
• Bulimia 8.1
• Chronic motor tics 3.2
• Anorexia 1.6
• Tourette‟s Disorder 0.005
Problems Seen To Co-occur With TTM
(cont.)
(Woods et al, 2006)
• 55% of adults with trichotillomania have a
comorbid psychiatric diagnosis
• 26% have an obsessive-compulsive
disorder
• 23% have major depression
• 23% have generalized anxiety disorder
Life Impairment Among Adult TTM Sufferers
(TIP – A Study)
%
• Avoided social events 40
• Avoided group activities 36
• Interfered with work on a daily basis 23
• Avoided going on vacation 20
(N = 1697) (Franklin et al, 2006)
Life Impairment Among Child TTM
Sufferers (TIP – C Study)
Based on parent report:
• 55.6% (n = 74) reported that their child avoided
social events as a direct result of pulling.
Based on child report:
• 54.9% (n = 67) of the child sample reported that
TTM made it more difficult to study
• 36.1% (n = 44) reported that their ability to do well
academically was impaired as a direct result of
pulling.
Medical Problems Associated With BFRBs
• Repetitive strain injuries – back, shoulders
• Tendonitis – wrists
• Eye irritations
• Trichobezoars – Gastrointestinal blockage
• Eye and gynecological problems due to
avoidance of medical visits
• Skin infections
• Scarring of the skin
What Causes BFRBs?
Various Explanations For Causes Of
BFRBs
• Psychodynamic
– Defense against sexual impulses or conflicts
• Biological
• Behavioral
- Self-reinforcing habit
• Ethological (Animal)
– Grooming disorder – hard-wired behaviors gone awry
– Displacement behaviors becoming stereotypys
• Emotional Self-regulation
• Addiction
• Genetic predisposition
– Stimulus Regulation – attempt to externally regulate
the central nervous system
PULLING AS A WAY OF REGULATING
STIMULATION
UNDERSTIMULATION OVERSTIMULATION
Provides stimulation Reduces stimulation
to relieve to relieve
Boredom Stress
Inactivity Excitement
Body-focused Repetitive Behaviors
Have Also Been Observed In Animals
• Dogs - Canine Acral Lick
• Cats - Psychogenic Alopecia
• Horses - Equine Self-mutilation Syndrome (ESMS)
- Cribbing
- Flank Biting
- Weaving
- Stall Walking
• Birds - Feather Picking
Canine acral
lick dermatitis
Canine acral
lick dermatitis
Feline
psychogenic
alopecia
Cribbing
Feather-
picking
Barbering Mice
TTM and other Body-focused Repetitive Behaviors
(BFRBs) have many inputs, and the treatment
requires a comprehensive approach that deals with
as many of these as possible.
• Biological
• Behavioral
• Emotional
• Sensory
• Cognitive
• Physical
• Environmental
Why Is It So Hard To Find
Proper Treatment For BFRBs?
TIP-A Study – Provider Knowledge
%
• Treatment provider an expert in TTM 3
• Provider knew a lot about the disorder 12
• Provider had “some“ knowledge of TTM 32
• Provider had at least heard of TTM 26
• Provider was “not at all knowledgeable” 27
about TTM
Woods et al, 2006
Sources of BFRB Referrals
• TLC
• The Obsessive Compulsive Foundation
• Association for Behavioral and Cognitive Therapy
(www.abct.org)
• The closest trich or OCD clinical expert (they often know
of other specialists in the region)
• Local trich or OCD support group
• University hospitals that have OCD/anxiety disorder
clinics
• Your county psychological association
• Trich websites on the internet (with certain reservations)
What To Ask When You
Finally Do Find Someone
• What degrees do you have, and are you licensed in this
state?
• Do you actually specialize in treating trichotillomania (or
skin-picking or nail-biting)?
• What are your qualifications for treating trich (or skin-
picking or nail-biting)? Have you had some type of
supervised training?
• How long have you been in practice?
• What is your orientation?
What To Ask When You
Finally Do Find Someone (cont.)
• What techniques do you use?
• What is your fee? Are your services covered by
insurance? Do you accept insurance reimbursement?
• On the average, how long will it take for me to see some
results with this treatment?
The End